IV Fluid Management for a 58-pound (26.3 kg) Child
For a 58-pound (26.3 kg) child, the appropriate initial IV fluid bolus in shock is 20 mL/kg (approximately 526 mL), with reassessment after each bolus and potential for up to 40-60 mL/kg in the first hour of resuscitation. 1
Initial Fluid Resuscitation for Shock
If the child shows signs of shock:
- First bolus: 20 mL/kg (526 mL) of isotonic crystalloid over 5-10 minutes 1, 2
- Reassess after each bolus for:
- Improved perfusion
- Normalized heart rate
- Improved mental status
- Signs of fluid overload
- Additional boluses: May require up to 60 mL/kg (1578 mL) total, given as three boluses of 20 mL/kg each 2
- Severe cases: Up to 200 mL/kg may be required if no signs of fluid overload develop 1
Maintenance IV Fluid Calculation
For maintenance fluids (if needed after resuscitation), use the Holliday-Segar formula:
- First 10 kg: 100 mL/kg/day (1000 mL)
- Second 10 kg: 50 mL/kg/day (500 mL)
- Each kg above 20 kg: 20 mL/kg/day (6.3 kg × 20 mL = 126 mL)
- Total maintenance: 1626 mL/day or approximately 68 mL/hour
Fluid Type Selection
- Resuscitation: Use isotonic balanced crystalloid solutions (preferred) or normal saline 2, 1
- Maintenance: Use isotonic fluids to reduce risk of hyponatremia 2, 3
Special Considerations
Fluid Restriction
For children at risk of increased ADH secretion:
- Restrict maintenance fluids to 65-80% of calculated volume 2
- For children with heart failure, renal failure, or hepatic failure, restrict to 50-60% of calculated volume 2
Monitoring
- Monitor vital signs continuously
- Assess capillary refill time, mental status, and urine output
- Watch for signs of fluid overload:
- Increased work of breathing
- Rales/crackles
- Hepatomegaly 1
Inotropic Support
- If shock is fluid-refractory after 40-60 mL/kg, consider starting inotropic support 1
- For peripheral administration:
- Epinephrine (0.05-0.3 μg/kg/min) for cold shock
- Norepinephrine for warm shock
Important Caveats
- Avoid fluid overload: Stop fluid boluses if signs of fluid overload develop 2, 1
- Account for all fluid sources: Remember to include IV medications, arterial/venous line flushes in total fluid calculations 2, 4
- Reassess frequently: The child's response to fluid therapy should guide further management 2
- Caution with severe febrile illness: In settings with limited critical care resources, use extreme caution with bolus fluid therapy in children with severe febrile illness 2, 1
Fluid Administration Method
For resuscitation boluses:
- Administer via push or pressure bag over 5-10 minutes 1
- Use large-bore IV or intraosseous access if venous access is difficult
For maintenance fluids:
- Use an infusion pump to deliver at calculated hourly rate
- Consider glucose-containing fluids (D5 or D10 in isotonic solution) for maintenance to prevent hypoglycemia 2